A client has sustained a crush injury to the abdomen as the result of an industrial accident. The initial assessment and interventions have been carried out. The vital signs are stable and the family is at the bedside. The client is complaining of bilateral flank pain. What is the priority nursing action for this client now?
Prepare for immediate abdominal surgery
Determine if there are any allergies to food or drugs
Administer antibiotics as ordered after culture results are available
Obtain a urine specimen
The Correct Answer is D
A. Prepare for immediate abdominal surgery
There is no indication of active hemorrhage or peritonitis at this point. Further assessment is needed before deciding on surgery.
B. Determine if there are any allergies to food or drugs
Allergy history is important, but it is not the immediate priority for this client.
C. Administer antibiotics as ordered after culture results are available
Antibiotics may be needed if infection is suspected, but the priority is assessing kidney function due to the risk of rhabdomyolysis from muscle breakdown.
D. Obtain a urine specimen
Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. The urine should be tested for myoglobinuria (tea-colored urine), hematuria, or kidney injury markers.
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Related Questions
Correct Answer is D
Explanation
A. Prepare for immediate surgery to repair the open fracture
Surgery may be necessary, but it is not the immediate priority. The focus should be on stabilizing the client and preventing further injury.
B. Assess for pulses in the upper and lower extremities
Assessing circulation is important but is not the most immediate life-saving intervention. First, the client must be stabilized and bleeding controlled.
C. Place a sterile pressure dressing on the open fracture
While controlling bleeding is important, spinal immobilization takes precedence in trauma cases to prevent potential spinal cord injury.
D. Maintain C-spine immobilization
In a trauma patient with loss of consciousness, cervical spine injury must be assumed. Immobilization prevents further damage while other interventions are performed.
Correct Answer is D
Explanation
A. Avoid using an electric razor
This is not directly relevant to trigeminal neuralgia management. Although it may be important for clients to avoid stimulating the face in general, an electric razor is not a specific concern for trigeminal neuralgia.
B. Meats should be served hot
Hot foods should actually be avoided, as extreme temperatures can trigger trigeminal neuralgia pain. Therefore, this recommendation is incorrect.
C. Teeth should be brushed prior to each meal
This is a reasonable recommendation for maintaining oral hygiene, but it does not specifically address managing trigeminal neuralgia pain. It is not as effective as the correct measure for managing trigeminal neuralgia.
D. Chew food on the unaffected side
Clients with trigeminal neuralgia may experience severe pain on one side of the face, especially when chewing. To reduce pain, it is recommended to chew food on the unaffected side to avoid triggering pain.
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